Gynecologic Malignancies in Older Women
Gynecologic Malignancies in Older Women
The demographics of the US population continue to change dramatically, as the absolute number and proportion of older people relative to the remainder of the population increases. Last year, the number of persons older than 65 years was estimated to be 35 million, representing almost 13% of the overall population; by 2030, the older population is expected to double. Along with the general aging of the population, the percentage of persons older than 85 years is also growing rapidly, as is the ethnic and racial diversity within the older population.
In terms of gender distribution, women represent 58% of those age 65 and older, and 75% of those 85 and older (a reflection of the longer life expectancy of women relative to men). If mortality rates remain constant, persons who were 65 years old in 2000 are expected to live to age 81, compared with a life expectancy of 77 years in persons 65 years old in 1900.
Older age, however, is accompanied by an increased risk of disease. Cancer is currently the second leading cause of death in older persons, behind heart disease only. Mortality rates for cancer have risen approximately 8% since 1980, compared with a 30% and 36% reduction in mortality rates from heart disease and stroke, respectively. The incidence of gynecologic malignancies (endometrial, ovarian, cervical, vulvar, and vaginal cancer) peaks in older women, and as such, the prevalence of these diseases will increase as the population ages. It is, therefore, important to recognize the influence of age on the screening, diagnosis, treatment, and outcome of gynecologic malignancies in women. The article by Dr. Mirhashemi et al provides an excellent description of gynecologic malignancies in older women, with emphasis on the relationship between age and treatment.
Screening and Diagnosis
The authors report further that the diagnosis of gynecologic malignancies is influenced by age. Like most cancers, gynecologic cancers occur more frequently in older women. Factors contributing to this include a decreased resistance, longer exposure to carcinogens, decreased immunity, and a decreased ability to repair the DNA replicative errors that occur with aging. Screening for malignancy may be less effective in older women due to fewer physician visits, a less structured social network, and an increased incidence of comorbid conditions that make such screening a lower priority in a woman’s overall health.
Specific to gynecologic malignancies, older women constitute a large proportion of the women who have not been screened for cervical cancer; more than half of women older than age 60 with cervical cancer have not had a Papanicolaou (Pap) smear in the 3 years prior to diagnosis. Thus, one-quarter of all cervical cancers and two-fifths of cervical cancer deaths occur in women over age 65. Similarly, many women with ovarian cancer have not had a pelvic examination in the years prior to diagnosis. These data emphasize the importance of screening older women for gynecologic malignancies with annual cervical cytology and pelvic examination as part of routine health maintenance.
Treatment decisions often change based on a patient’s age. Based on age alone, older patients are offered less aggressive primary, adjuvant, and salvage therapy (including surgery, chemotherapy, and radiation) for their malignancy due to concerns regarding toxicity. This population is also underrepresented in clinical trials, either because of patient preference or physician bias stemming from a lack of data on the efficacy of treatment in older patients. Clearly, older populations have more comorbid conditions, use more medications, and may be more nutritionally depleted than younger populationsall of which contribute to changes in drug pharmacokinetics.
Given that the majority of women diagnosed with ovarian cancer will require chemotherapy following surgery, and that many patients with cervical cancer will receive primary irradiation and concurrent platinum-based chemotherapy, an understanding of drug metabolism, excretion, and kinetics is imperative when administering these agents to older women.
As Dr. Mirhashemi et al comment, patient age, as it relates to comorbid conditions and inherent changes in pharmacokinetics, is an important consideration when assigning a treatment for cancer. Prompt recognition of treatment-related complications (eg, dehydration and anemia) and interventions to prevent sequelae may be more important in older patients with comorbid conditions than in their younger counterparts.
Unfortunately, older patients with cancer have a poorer prognosis than younger patients. Although this may be related to comorbid conditions influencing an older patient’s ability to undergo standard treatment, it is important to recognize the differences in outcome between older and younger populations. With respect to gynecologic malignancies, evidence has shown that older women with ovarian, endometrial, or cervical cancer have a worse prognosis than younger women. As suggested by Dr. Mirhashemi et al, efforts should be made to prescribe the appropriate therapy to older women for their disease so as to maximize cure in this population. It is also important to ascertain whether the tumors in this population are more virulent, based on different molecular biological characteristics.
As the population ages, more older women will be diagnosed with gynecologic malignancies. We must continue to be vigilant in screening older populations for these cancers as part of their routine health maintenance because many older women who are diagnosed with these malignancies have not undergone screening. It is also important to increase our education about the effects of the treatment of gynecologic malignancies in older populations as they relate to comorbid conditions, concurrent medications, and the metabolism, excretion, and pharmacokinetics of chemotherapeutic agents.
Efforts should be made to prescribe the appropriate therapy for women with gynecologic malignancies independent of age, as well as to enroll older patients in clinical trials to determine the efficacy of treatment. These goals should lead to improved detection, therapy, and outcomes for older women with gynecologic cancers. Dr. Mirhashemi et al have contributed to our understanding of gynecologic malignancies in older patients.
1. Older Americans 2000: Key Indicators of Well-Being, pp 1-123. Hyattsville, Md, Federal Interagency Form on Aging-Related Statistics, 2000.
2. National Institutes of Health: Cervical Cancer: NIH Consensus Statement, April 1-3, 1996. 14(1):1-38, 1996.